Happy International Children's Day!

I am a member of a google group for Battambang. Its a useful forum for advertising, sharing ideas & asking for advice. There are some members whose dry wit & deep seated sense of irony really cheer me up & put a smile on my face. Below is an example of my favourite poster - I've never met him but I know it would be an interesting conversation over a beer if I ever did.


"As this Friday is International Children's Day, please take note of
the following:

THE BAMBOO TRAIN BRICK FACTORY WILL BE CLOSED
THERE WILL BE NO URCHINS COLLECTING TIN CANS OR PLASTIC BOTTLES FROM
THE STREET
BLIND BEGGARS WILL BE USING DOGS TO GUIDE THEM AROUND THE STREETS
NO BOOKS OR POSTCARDS WILL BE ON SALE IN SIEM REAP

Thanks for your understanding, exploitation and child labour will
resume normal service on Saturday, 2 June"

10 000 days

http://www.nytimes.com/2012/06/01/opinion/10000-days-of-hun-sen.html

http://www.bbc.co.uk/news/world-asia-18093818


This weekend is election time in Cambodia. I was informed last night that Hun Sen has decreed that the 3 days (Friday is International Children's day) will be alcohol free to facilitate a 'smooth' democratic process.

The last few weeks have been dominated by the white & blue uniforms of the CPP (Cambodian People Party) - convoys of SUVs, Motos, tractors pulling trailers of people all loyally wearing their CCP caps block the roads. The election propaganda blares out from loud speakers, traffic is brought to a halt & the thin veneer of democracy is translucent.

To have any job within the public sector in Cambodia one must be a paying member of the CPP. A large proportion of the Cambodia population are under 25 years old - the emerging new hope.

Talking with the younger generation of Cambodians I've been asking them who they will be voting for in the up coming elections. They fall into three categories;

1) They will not discuss

2) They will not vote - what is the point, their vote 'doesn't count'

3) They will vote for any party other than CPP in an attempt to practice their democratic right & will encourage friends & family to do the same.

Given the history of this country surprisingly few are category 1), understandably some are 2) but the majority are 3) - one person is having their marriage license withheld by their commune chief unless they vote CPP in there home district but they refuse to be intimidated.

The links above say more than I can say here.

Psychosclerosis

A while ago now, in-between the many public holidays that punctuate this time of year, I was in the hospital showing a short term volunteer from the Microbiology lab around the ICU medicine ward. She - R - was keen to talk to the doctors & nurses on ICU medicine about sending more samples for microbiology testing. The lab has been established for almost a year but changing health workers habits, whether that is requesting investigations or prescribing, readers of this blog will appreciate, is rather challenging. R wanted to 'remind' them that they could send blood cultures, CSF, urine, wound swabs etc. They were all sat around, looking very relaxed, watching karaoke so I'm not sure how much was absorbed.

R then requested to look around the ICU ward, before we even got to the first room I could see that this was not a good time for sight-seeing. Through the crack in the door I could see a man Cheyne-stoking (the last breaths of a dying man) with his wife crying over him. The 2 other patients & their relatives were looking on mutely. The nurses & doctors you will recall were sat watching television in the staff room. I expressed that this wasn't a good time to intrude on a dying man's last moment but my non-medical VA & the non-clinical R thought it was fine, she couldn't accept that there was anything seriously wrong with the patient because to her he looked perfectly well.

I went to find Dr L to find out why a man was dying & being ignored by all the staff who were all still sat in the staff room watching bad Cambodian TV. Apparently he had Hepatitis B, liver failure & encephalopathy which would explain why he was jaundiced & in a coma. The wife wanted her children who were 2 hours away to come & be with their dying father but it seemed that this wasn't going to be possible - money & time were both limited.

I went back to explain the situation to R but I found her crying with the inconsolable wife. The man started to vomit blood - I called for some help & without gloves or an apron I rolled the man over by myself to hold him on his side. One could argue this was a pointless intervention but I really can't bear to see an obstructed airway, even in a dying man. My VA has an aversion to body fluids, R & the wife were both paralysed by sobbing & the rest of the relatives passively looked on.

Two student nurses arrived - they saw me trying to help the man to have a semi-dignified death & just started giggling joining the audience mounting now in the door way & ward window consisting of various patients, relatives & monks.

The man died.

The wife became hysterical with grief. R started taking photos of the whole spectacle. It was truly one of the most surreal deaths I have ever been witness to, although it probably will make me sound like a terrible doctor, I have been present at quite a few. R wanted to take photos of the wife with her dead husband & for my VA to take photos of R with the wife & dead husband AND me with them also. My english reserve & sensibilities kicked in. The bereaved wife seemed to be buying it all though so who was I to judge. (R later went & got the photos printed out for the wife to take back to her village, for her & her children.)

Then the wife ran off to cry outside very loudly & telephone her children. Generally here people take pain, suffering & death quietly, it is quite unnerving & so it was a relief to have a physical & auditory response for a change. When she returned R had organised for her to clean & prepare her husband's body. This is something that in the UK would be done by the nursing staff but his widow, me & a short term microbiology volunteer managed to do a reasonable job.

R was crying as much as the wife - her face wet with tears & snot, the wife was clinging to me sobbing onto my shoulder, making my top wet with her tears. The other relatives in the ward even had tears in their eyes by this point & I found myself dry eyed,  stood grimly thinking, 'am I emotionally closer to the ICU staff who are still just sat watching TV & snacking in a room 6 metres away?' Surely what was happening in this room was much better than any Korean soap opera could offer them?

Atherosclerosis is hardening of the arteries & as one of my moodscope emails recently told me psychosclerosis is hardening of the attitude. This I believe is definitely an issue here and some times I worry that it may even be contagious.

For the past 6 weeks, since but not directly related to this event, I have cried at least once a day - so I think my tentative self diagnosis of psychosclerosis was premature but I'm willing to accept 'burn-out' instead!

De-skilling or Up-skilling

It took me 14 years of schooling - 11 of them of which I knew I wanted to be a doctor. Then 5 years spent as an undergraduate at Medical School, 1 year as a house officer (intern/foundation year 1 - what ever they're calling it now), 3 years as a SHO (senior house officer) before going to work in Australia as a registrar for 2 years (with a couple of expedition medic outings on the way), another year of being an SHO before a year as a middle grade in emergency medicine (slipping in a diploma in tropical medicine & hygiene & my Membership exams). Finally I got a training number for emergency medicine for 5 years & came out with my fellowship exam & sub-speciality training in paediatric emergency medicine, a diploma in child health & very nearly a MSc in child health (dissertation pending). I worked for 14 months as a consultant in the NHS & it took me precisely 11 months in Cambodia before on a bus journey down to Phnom Penh I turned to J & came out with the classic freudian slip, "When I was a doctor..."

I have spent almost my whole life wanting, studying, training & working to be a doctor but in less than a year I had reached the point where I don't even consider myself to be one any more. This is what I like to call 'de-skilling'.

How, I hear you cry, can 21 years of medical education & training be lost in less than a year? Well the grand canyon was worn away by just water & the dripping tap of mistrust & disbelief has been eroding away at my self confidence over the last 15 months. Admittedly quicker than the formation of the grand canyon, I have now reached the point where I doubt myself over the most basic medical knowledge.

Example: at a recent ECG workshop following an ECG lecture, given by a delegation from a famous American University, my group were debating the tricky concept of QRS length & what is normal. I told them it was less than 3 small squares which represents 0.12 seconds. The 6 male Cambodian doctors in the group refused to believe me - I double checked with the lecture because I've only been teaching ECGs in ALS for 9 years now.

"You are wrong!" I was confidently told by a doctor whose hospital does not have & has never owned an ECG machine. ON (my deputy director) finally got to the root of the problem - I had been referring to small & large 'squares' where as the Americans had called them 'boxes' in the lecture. This it would appear had put my whole credibility to read ECGs into disrepute. I thought it was a little pedantic to point out that a 'box' is a 3-dimensional shape where as a 'square' more accurately describes the grid pattern of ECG paper. Instead I went for the more rational approach of asserting it was less than 0.12 seconds but again I was dismissed. The lecture quite clearly stated it was less than 120 milliseconds - this it would appear is completely different & I am therefore just a semi-literate & semi-numerate fool. It was at this point I gave up.

Which is odd as what usually happens to a lot of people in development is more, what someone I respect very much calls, 'up-skilling'. Non-medical people become medics, nurses become doctors, GPs become neurosurgeons etc. etc. etc.... you get the idea?

And I'd be lying if I said that this hadn't from time to time also happened to me, but I hope I have the self awareness & insight to recognize & moderate it. So for example since being here I have been deemed an expert in children with disabilities. A couple of volunteers have asked me to go out into the community to see children, it gets me out the hospital. Although I can manage an acutely sick child I wouldn't say I knew an awful lot about chronic problems, but I side step this by referring on to NGOs & hospitals that I know are experts or at least can help the children more than I can.

At a recent clinical case review of a child with Dengue recently, when I was asked for my opinion on the management, I deferred to the local doctors who have treated more cases of Dengue than I have had hot dinners.

Last Friday J & I found ourselves on the Paediatric ward advising a young mother, with her severely malnourished 2 month old, on re-lactation & breast feeding. J's last job in the UK was working as a ward manager of an adult medical ward, neither of us are midwives or breast feeding experts (J at least has done it once!). We both could see the funny side of stood in the middle of a ward squeezing our breasts & embarrassing R (Cambodian & male) who was translating for us. The first time mother from a village on the Thai border had stopped breast feeding after one month because of a breast infection & had fed her baby on soya milk & water. J & R found the child being treated for pneumonia at the CPA 2 hospital they visit once a month & had pointed out to the staff there that baby also had severe kwashiorkor & required transferring to Battambang - J isn't a paediatric nurse either but sometimes up-skilling comes out of necessity.

Guns don't kill people.....

One of the arguments that the NFA in the USA uses to support their belief that every citizen has the right to bear arms is the statement "guns don't kill people, people kill people."

This week a visiting delegation from the states has turned this argument on its head from a medical perspective. Hence I have learnt that it isn't health care professionals that save patients lives - it a automated external defibrillator (AED).

This is awkward as for the last year I have been explaining to my hospital that in the UK only 20% of in hospital cardiac arrest are a 'shockable' rhythm (no one knows what the figures for Cambodia are) & that with out adequate post resuscitation care the chain of survival is still weak. I've argued for capacity building basic & essential emergency care - basic airway management, importance of vital observations, good history taking, following evidence based protocols etc. etc. etc.

Of course the hospital want state of the art, shiny, new medical equipment & I don't debate that they deserve it, but like Maslow's pyramid - heirachy of needs in humans there is, I believe, the same principle to providing adequate emergency medical care. There is no point having a defib machine when nurses fabricate observations & there is no real nursing care or doctors can't manage basic airways or follow a simple Asthma protocol etc. etc. etc. This concept is sometimes hard to convey in a country where it is all about status & money.

So ON my deputy director gave me physical goose bumps & caused me to be culturally inappropriate when unprompted he agreed with me. We were both at an emergency seminar where the resurrection abilities of the AED were being lauded.

Preparing myself for a very long conversation about AED I sidled up & asked him what he thought. "Well Esther - an AED is very expensive & we have many things to buy for the new ER with very limited budget. I don't think an AED is first our priority - we need to sit down & prioritize equipment based on need & cost, lets meet Friday after this course."

I hugged him.

Angry Bird or Going Troppo part 2

Mr S - the head nurse at my hospital has started to call me 'Angry Bird' - he says it with affection & it is usually accompanied with a statement such as "Thank you for staying Esther, I know we frustrate you but I want you to know that I appreciate you." Shortly following this he will then ask me to do something for him, I will say 'yes', it works every time.

Angry Birds - a merchandise sensation here in Asia - is in fact a very fitting term of endearment for me because currently I am angry most of the time (although as a feminist I would usually object to being called a bird - it makes me angry!). I've been hoping that this is all down to the heat & 'going troppo' will vanish with the rains but I fear that there is a deeper rooted cause that a drop in ˚C is not going to address.

You will only have to read my previous blogs to get a general idea about what kind of things cause me to become frustrated & angry. My development of a visual analogue scale probably is a good indicator as to how much time I have been feeling this way recently.

Last month I under took a health facility review, for VSO, of a group of counsellors in Phnom Penh. 60% of their clients are Cambodian, mainly presenting with post traumatic stress & anxiety disorders. When I asked what the 40% ex-pats common complaints were, the answer was Culture Shock. This can present with many symptoms - poor appetite, sleep disorder (but that could be Wat related!), anxiety, depression, irritability.... Then I tentatively asked "Anger?" - apparently yes!

However I don't think that I am culture shocked, I don't believe I am going troppo, what I am experiencing is just a normal reaction to current life events. From  Cambodia to UK, work to home, professional to personal, regional politics & gender issues to bad driving - everything is driving me crazy.

But who I'm really angry with the most is myself & my failure to shake this angry bird trap. So if someone could please catapult a bird in my direction, release me from this cage & get a bonus pineapple for your troubles, it would be very much appreciated.

The worst boss or job in the world?

It's fair to say at the moment I am feeling a bit of a failure - both professionally & personally - so it came as a surprise that I managed to see my latest setback in a positive light. My VA has handed in his notice. Afterwards I cycled home thinking about the massive problem this poses for me (I currently don't have a work-plan for the coming year & now no VA to negotiate or translate a plan or time in the next month to recruit a new one) it occurred to me - surely I must hold the record for the volunteer who has had the most VAs in a single placement (I am in search now for my 4th). I may be a failure - but I am a record breaking failure.

I don't blame the boy for leaving, he recently lost the best bit about his job which was working the other half of his time with the lovely Kristy. She left a month ago, back to sunny Australia & he has been pretty gloomy since (To be fair so have I). Working with Kristy half the time he got to sit in a AC lab - translating documents with not much verbal interpretation & translation, he got on with the lab staff - especially the pretty, young ones.

With me his job is slightly different. We walk the length & breadth of the hospital in search of staff to capacity build. He soon learnt that his smart, metrosexual shoes gave him blisters from all the walking he does with me so for the half days he is with me he now wears flip flops.

When we find staff - they are often mean & hostile to us. He tends not to translate what they are saying if it is very bad, but only a small part of communication is verbal, so I usually get the message. I make him say challenging things to the staff, I sometimes disagree with their management, I make more work for them with my suggestions, I question the status quo, I rock the boat - he absolutely hates translating for me. Part of the problem is that he is not from a medical background so can not always understand the medical khmer which is used. Also he is young (21) &  an english/management student who has a very limited biological/sciences background. Then there is the added complication of doctors half talking & writing in french. It renders most of the conversations (especially in meetings) impossible for my (ex)VA to translate. Imagine how unintelligible an average English doctor can be when they are on a medical jargon roll, then put that to the power 10 & that is my VAs nightmare.

When I do training even the URC nurses & doctors that I work with sometimes struggle to translate some of the concepts into Khmer from my English. I'm beginning to lose the ability to communicate in simple English & unfortunately it hasn't been replaced by Khmer or French. Without adequate communication I am nothing.

Then if that wasn't enough with his blistered feet, injured feelings & bruised language skills, I then drag him to see bleeding, dying, suffering, distressed, seriously ill patients in smelly, dirty, appalling wards. And when the staff don't listen & are rude, and when the patients die needlessly and when it is all too much for me, I ask him "why?", because he isn't just my translator he is also my cultural guide. He doesn't have the answers & as he has written in this blog previously he feels the same way as me.

He does all this for $120 a month (part time). He tells me his new job is his "dream job". Unspoken in that statement is that this one is his absolute worst!

So you see I can completely understand why he is leaving - if I wasn't so stubborn & not a quitter I'd be right behind him.

So I am looking for a cheerful, resilient Cambodian - preferably from a medical background, with good English & medical French, who is confident, can put up with a lot of hassle from hospital staff & me, has good interpersonal skills & doesn't mind the worst boss in the world or doing the worst job in the world for a modest salary. Comfortable shoes are essential. All applicants will be considered.